Small Employer's Health Plan Compliance Checklist for the
Pub. L. No. 111-148, as amended, introduced numerous
additional substantive and procedural requirements for group
health plans and employers sponsoring those plans. The
compliance checklist is intended for employers with fewer than
50 employees in communications with a health insurance issuer
providing coverage for their employees. It lists significant
factors involved in compliance with the
the plan to ensure that it has not done anything to lose
the plan to make sure that it has been amended to comply with
the health care reforms to which it is subject (i.e., beginning
in 2014, the plan cannot have any preexisting condition
exclusions and cannot apply a waiting period of more than 90
days). See below for a list of health insurance reforms.
that a Notice of Grandfathered Health Plan Status is included in
any plan materials describing the benefits provided under the
plan, including the summary plan description (SPD).
the plan to verify that modifications necessary to comply with
the group market reforms (generally effective for plan years
beginning on or after September 23, 2010) were incorporated.
administrative procedures to make sure that plan is complying
any restricted annual limits on essential health benefits (EHBs)
for plan years beginning on or after January 1, 2014. Thus, no
mini-med plans covering EHBs may be offered.
the plan was granted a waiver on restricted annual limits, it
had to resubmit by December 31, 2013, the information provided
to obtain the waiver.
Insurance Market Reforms:
the plan to verify that changes needed to comply with insurance
market reforms are incorporated, generally effective for plan
years beginning on or after January 1, 2014. These include:
waiting period greater than 90 days;
preexisting condition exclusions for adults or covered children
under age 26;
annual cost-sharing imposed cannot exceed
imposed limitations (e.g., for the 2014 plan year, out-of-pocket
maximums of $6,350 for self-only coverage and $12,700 for other
coverage; for the 2015 plan year, maximums of $6,600 and
$13,200, respectively), except that relief from the
out-of-pocket limitation is available for the 2014 plan year to
certain employer-sponsored plans that utilize multiple service
providers to administer affected benefits;
fully-insured plans, cover essential health benefits;
for specified clinical trials;
discrimination based on health status-related factors, including
compliance with wellness program rules; and
the plan document, SPD, and administrative procedures.
that procedures are in place to provide the appropriate patient
protection disclosures (e.g., access to health care
professionals, coverage of emergency services) whenever the plan
provides a participant with an SPD or other similar description
of plan benefits.
that the Summary of Benefits and Coverage (SBC) was timely sent
to participants and beneficiaries and make sure that procedures
are in place to deliver the SBC upon request and in particular
situations (such as special enrollment).
SBC template used for 2014 and for 2015 differs from the
previous template. Confirm that the appropriate SBC template is
being used. See http://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/Downloads/sbc-template-accessible.pdf.
the requirement to provide 60-days advance notice of any
material modification in any plan terms, review procedures for
determining whether changes are material modifications and for
procedures for providing notices related to the claims appeals
procedures are in place to provide a Notice of Health Insurance
Marketplace Options to new employees within 14 days of their
that Form W-2
informational reporting of employer-sponsored health coverage
reflects any changes made to health plans offered.
a wellness program is offered, make certain that required
notices are provided.
employer is a religious organization that claims an
accommodation regarding contraceptive services coverage, the
issuer or third-party administrator provides notice to plan
participants and beneficiaries of the availability of separate
contraceptive coverage. However, the employer must ensure that
accommodations requirements are satisfied, which includes making
the self-certification available for examination upon request by
the first day of the plan year.
Care Coverage Options:
employer may offer employees the opportunity to obtain coverage
in a Small Business Health Options Program (SHOP) Exchange
through its cafeteria plan. Rolling enrollment applies, so
consider whether to begin offering coverage through the SHOP
instead of sponsoring a group health plan or offering no
the employer meets size and salary criteria to be eligible for
the small business health care tax credit (i.e., fewer than 25
full-time equivalent employees with average annual wages under
$50,800 for 2014 (under $51,600 for 2015)), consider whether
coverage should be offered through the SHOP Exchange so the
employer can claim the tax credit for premium contributions.
employer growth, including employers that are combined under the
controlled group rules. Employers with 50 or more full-time
equivalent employees in the preceding year will be subject to
the employer shared responsibility penalty (for months beginning
in 2015, or for months beginning in 2016 if they have fewer than
100 such employees and meet conditions related to workforce,
employee hours and previously offered coverage) if they do not
offer coverage that is minimum essential coverage or they offer
coverage that is not affordable or does not provide minimum
cafeteria plan for transition relief regarding salary reduction
elections without a change-in-status event and for changes to
flexible spending account rules.
reinsurance fees for 2014 are due in 2015, and enrollment data
is due to the Department of Health and Human Services by
December 5, 2014 (extended from November 15, 2014). The issuer
pays the fee for insured plans.
Outcomes Research Institute (PCORI) fees are due by July 31 of
the year following the end of the plan or policy year. When the
temporary fee is imposed on certain self-insured health plans,
such as health FSAs and HRAs that are not excepted benefits, it
is paid by the plan sponsor. When it applies to health insurance
policies, it is paid by the issuer. Any payment due for the
first year should have been made by July 31, 2013. If the
employer owed any fee, ensure that the filing was made and that
no amended form is required to make corrections.
HEALTH PLAN CONSIDERATIONS
addition to reviewing for compliance with the
continue to review practices and procedures for furnishing
health plan-related notices, including special enrollment rights
under HIPAA, the annual Women's Health and Cancer Rights Act
Notice and Medicare Part D notices. Verify that the COBRA
election notice being provided (and required unless the employer
does not meet the 20-employee threshold for federal COBRA to
apply) is the version updated in 2013 to mention that
alternatives may be available through the Health Insurance
HIPAA/HITECH practices and procedures, including business
associate agreements and privacy notices, for compliance with
2013 regulatory requirements.
spousal coverage following United States v. Windsor:
plan to determine whether it must be amended to ensure the same
treatment of opposite-sex and same-sex spouses for federal tax
whether procedures must be modified to stop imputing income to
state tax treatment differs, make sure that procedures are in
place to comply with both state and federal law.